The Ready-to-Learn Program: A School-based Model of Nurse Practitioner Participation in Evaluating School Failure Eleanor Adams, Amy R. Shannon, Paul H. Dworkin

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ABSTRACT: The Ready-to-karn program, a school-based initiative begun in 1994 in three inner-city elementary schools in Hartford. Conn., provides medical input and medical-educational collaboration in the evaluation and treatment of children experienc- ing learning and behavior problems. The program is staffed by two specially trained nurse practitioners, with consultation provided by pediatricians and a child psychologist. During its first year of operation, pediatric assessment was performed on 57 students at all three schools. Data analysis indicates that children were referred to the program for a broad range of concerns. that assessments were completed in a timely fashion, and that a variety of diagnoses were identified. Feedback from school personnel and parents suggests that the program offers a unique and valued pediatric perspective to the evaluation of school failure. Future plans include a more formal evaluation of the program’s cost and effectiveness. (J Sch Health. 1996;66(1):242-246)

valuation of children experiencing school failure must E address a myriad of possible contributing factors. Learning disabilities, mental retardation, temperament or behavioral style, attentional difficulties, social or emotional issues, the school environment, chronic illness, and devel- opmental delays all may contribute to school children’s learning and behavioral difficulties.’ Schools and families view many of these potential causes of school failure to be medical in nature. Consequently, many children are referred for medical assessment as part of the overall evalu- ation process.

Medical assessment of children experiencing school fail- ure traditionally includes a history (medical, developmen- tal, academic, family, and social), physical and neurologi- cal examinations, and in-office observations.’,2 Additional strategies include structured interviews, standardized neurodevelopmental assessments, parent and teacher ques- tionnaires, and structured classroom observations.’

Medical assessment of school failure typically occurs in the relative isolation of the practitioner’s office, removed from the child’s academic and social environments. Children are seen within a clinic or office setting episodi- cally, for limited periods of time. Their behavior and performance within this setting is often atypical and, there- fore, may not accurately reflect their usual functioning within the classroom and home setting^.^

School-based medical assessment of school failure offers the opportunity for a more “natural,” longitudinal assessment of the child experiencing academic difficulties. School-based health clinics have proven effective in addressing a variety of children’s medical needs including health education, primary and acute care.5 The success of these clinics suggests that school-based medical assessment of children experiencing academic difficulties may be a feasible adjunct to existing school services.

Nurse practitioners have proven capable and effective providers in a variety of roles and settings.6 Their holistic approach to the individual traditionally includes the assess- ment of medical, developmental, social, and behavioral

Eleanor Adams, MSN, Family Nurse Practitioner; Amy R. Shannon, MSN, Pediatric Nurse Practitioner: and Paul H. Dworkin, MD, Professor and Head, Division of General Pediatrics, University of Connecticut School of Medicine, Farmington, and Director and Chairperson, Center f o r Children’s Health and Development, Saint Francis Hospital and Medical Center, I14 Woodland St., Harrford, CT 06105. This article was submitted Januarj 22, 1996, and revised and accepted for publication July 8, 1996.

factors. Additionally, the nurse practitioner’s focus on prevention facilitates the early identification of health care needs. This training and philosophy is well-suited to the assessment of the complex issue of school failure.

This paper describes a school-based program staffed by nurse practitioners who participate in the evaluation of chil- dren experiencing school failure. A pediatric neurodevelop- mental model is used in the program.

THE READY-TO-LEARN PROGRAM The Ready-to-Learn program, a school-based initiative

begun in Hartford, Conn., in 1994, is aimed at addressing the broad issue of school failure within the inner-city elementary school setting. The program provides medical input into the evaluation of children experiencing academic andor behavioral difficulties. It also encourages medical- educational collaboration in planning for services to address identified needs.

From the mid-1970s to 1987, the Hartford school system provided medical input to the evaluation of children experi- encing academic difficulties through the establishment of centrally located Preschool and Elementary Diagnostic Centers. At these Centers, referred children received multi- disciplinary evaluations over a two-week period, including psychological, educational, social service, speecManguage, and pediatric consultations, as well as a trial of diagnostic teaching. The Centers evaluated 80-100 children per acade- mic year. Despite being valued and well-received by school personnel and parents, budget restrictions resulted in the closing of the Centers after approximately 10 years of oper- ation.

Since 1987, the evaluation of children within the Hartford school system who are experiencing academic difficulties has lacked medical input, despite the fact that biologically based disorders often play a role in learning problems. The school system’s evaluation process tradi- tionally has included educational andor psychological test- ing and social services assessment, but often has not provided access to key medical consultation. Children who require medical assessment either are referred to their primary care providers or, at the parents’ and providers’ request, to community-based subspecialists, such as devel- opmentalhehavioral pediatricians, pediatric neurologists, or hospital-based multidisciplinary clinics. Most primary care providers defer assessment of school failure to subspe-

242 Journal of School Health September 1996, Vol. 66, No. 7

cialists.’ The limited availability and capacity of these subspecialists contribute to delays in diagnosis and, conse- quently, to delays in the implementation of necessary services. The need for external referral often has hampered communication between medical providers and school personnel.

The Ready-to-Learn Program is a collaborative effort among St. Francis Hospital and Medical Center (a large, urban, not-for-profit teaching hospital), the Hartford Board of Education, and the Archdiocese of Hartford. Grant monies raised by a community charitable event provided the initial funding for the project. Additional support came from funding from the Connecticut Dept. of Social Services. Although no clinical revenues presently are generated, direct reimbursement for services may be feasi- ble in the future. Operational costs include salaries for two nurse practitioners (covering three schools and a total of 1,200 students); testing materials; and nurse practitioner inservice training. Consultations to the nurse practitioners are provided on a weekly basis by three developmental- behavioral pediatricians and one child psychologist as in- kind contributions from the Center for Children’s Health and Development at Saint Francis Hospital and Medical Center. At present, guaranteed funding will support the program for a total of at least three to four years.

The goal of the Ready-to-Learn program is to facilitate early intervention for children in cases of school failure. Specific objectives include increasing communication between the medical and educational systems; increasing access to medicalheurodevelopmental evaluations; and providing an opportunity for medical consultation to school personnel and families.

The Ready-to-Learn program has several unique features as an approach to the evaluation of school failure: medical evaluations are performed by specially-trained, on- site nurse practitioners; nurse practitioners work within the school setting as one component of a multidisciplinary assessment team, while (as employees of St. Francis Hospital and Medical Center, rather than the Board of Education) also offering children and their families an inde- pendent, “outside” evaluation of their concerns; the on-site location of the program speeds the pediatric evaluation process, thereby increasing the likelihood of early identifi- cation of problems; and the program also increases commu- nication between health care providers and the schools.

Training Training of the program’s nurse practitioners was

accomplished through a six-month internship at the Center for Children’s Health and Development of Saint Francis Hospital and Medical Center. Hospital-based consultation clinics for developmental delays, behavior problems, and learning disabilities evaluate children for medical, psycho- logical, and educational causes of school failure. The clin- ics are staffed by a team of developmental pediatricians, a child psychologist, an educational diagnostician, and a nurse. The nurse practitioners worked closely with this team during the 6-month internship.

Under staff supervision, they observed and participated in team evaluations, conducting parent interviews, perform- ing physical examinations and neurodevelopmental assess- ments, and participating in the formulation of impressions and recommendations. i n addition to their clinical experi-

ences, the nurse practitioners acquired a working knowl- edge of the literature on school failure. They also attended conferences and workshops as a continuing education component of the program. The nurse practitioners continue to refine and expand their knowledge and clinical skills by working in the hospital-based consultation clinics one day each week during the school year, and full-time during school vacations and the summer months.

Site Descriptions Two elementary schools in the Hartford Public School

district and one parochial elementary school i n the Archdiocese of Hartford were selected as sites for imple- mentation of the Ready-to-Learn program. Selection crite- ria included the schools’ perceived need for services, acceptance by the school administration, geographical proximity to Saint Francis Hospital and Medical Center, and physical space to accommodate the program within each school. All three schools are urban sites. School popu- lations range from 200 to 600 students and include Hispanic, African-American, and West Indian groups as ethnic majorities.

Each nurse practitioner has responsibility for approxi- mately 600 students, since one serves the larger public school, while the other serves the smaller public school and the parochial school. A full-time social worker is available to provide limited counseling services at each public school. Traditional school health activities, such as mandated health screenings and immunization monitoring, emergency medical situations, and health education are the responsibility of a school nurse at each school. Psychological and educational testing services are also available at all schools.

Program Implementation In its first year of operation, the Ready-to-Learn

program sought to establish itself within the framework of existing school programs and protocols to enhance the eval- uation of children with school problems. Sources of refer- rals for pediatric assessment included teachers, parents, and the school’s Planning and Placement Team (PPT) - a group responsible for overseeing the evaluation and management of children with school difficulties. Referrals were encouraged for children suspected of having such biologically based disorders as attention-deficit hyperactiv- ity disorder, or medical problems interfering with school performance such as lead poisoning, iron-deficiency anemia, asthma, and seizures.

The main focus of the nurse practitioners’ daily activi- ties at the school was the assessment of referred children. Assessments consisted of an interview with parents, the completion of parent and teacher questionnaires, structured observations, a focused physical examination, and neuro- developmental examination.

History-taking included the maternal prenatal history and the child’s medical and developmental history. Parent and teacher questionnaires elicited further information and concerns about the child’s current functioning. Structured observations took place within a number of settings in the school, such as classrooms, the lunchroom, and the play- ground.

The interview with the child elicited information about the child’s feelings about school, home, and self. The phys-

Journal of School Health September 1996, Vol. 66, No. 7 243

ical examination included examination of eyes, tympanic membranes, skin, standard neurological examination, eval- uation of phenotypic features for minor congenital anom- alies, and assessment of vision and hearing. The question- naires and neurodevelopmental assessment tools of the Anser System, developed by Melvin Levine, MD, were used to assess the child’s developmental strengths and weaknesses and to create a structured setting for observa- tion of attention and activity, as well as solicit information from parents and teachers.* The goal of such assessment is to determine the extent to which strengths and weaknesses in various areas of development affect school functioning and offer recommendations to improve school perfor- mance.

Other activities included attending PPT meetings at the schools, communicating with outside agencies, medical consultations with school nurses, and weekly meetings with the program’s pediatric consultants to discuss assessments and management.

PROGRAM EVALUATION Evaluation of the the Ready-to-Learn program’s first

year of operation included a review of program data and discussions with teachers and parents from the three program schools to identify the program’s strengths and weaknesses. All provide valuable insight into the program’s effectiveness and have implications for future planning.

Data analysis of the first year shows that a total of 57 children were seen for pediatric assessment, including 4 1 boys and 16 girls (Table 1). Twenty-nine were of African-

Table 1 Characteristics of Children Referred

to the Ready-to-Learn Program at Each of the Three Participating Schools

Approximate population Total number evaluated Age at referral

Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11

Male Female

Gender

Public School A 6M)

26

2 10

1 6 1 3 3

18 8

Public School B 4M)

23

1 10

4 3 3 1 1

19 4

Parochial School 250 8

1 3 2 1 0 0 1

4 4

Ethnicity African-American 5 20 4 Hispanic 21 3 4

Kindergarten 5 2 1 First 7 14 4 Second 2 1 1 Third 5 3 1 Fourth 4 1 0 Fifth 2 2 1 Sixth 1 0 0

Grade

Referral source Teacher 5 19 8 Parent 2 1 0 PPT/SST 19 3 0

American or West Indian descent, and 28 were Hispanic. The ethnic makeup of the referral population approximated the ethnic makeup of each school’s population. Ages ranged from five to 11 years. Grade at time of referral ranged from kindergarten to sixth. The largest percentages of referrals came from kindergarten through third grade. Most referrals (94.8%) came from school personnel. Referrals reflected a variety of concerns including atten- tion, academic difficulties, behavior, activity level, and developmental issues. Most children were referred for multiple concerns.

Length of time from referral to completion of the assess- ment ranged from five to 131 school days, with an average of 41.5 days. Of those referred, 50% were evaluated in 38 days or less, 75% of evaluations were completed in 49 days or less.

Diagnoses based on the assessments included likely emotional/social problems, developmental delays, atten- tional difficulties, issues relating to temperament or behav- ioral style, and school performance difficulties due to medical problems such as asthma or seizure disorders. In many cases, children were identified as having multiple areas of need. These were addressed through recommenda- tions such as medical management, including pharmaco- logic treatment, behavior management strategies, referral for additional educational andor psychological testing, and mental health counseling. In general, more than one recom- mendation was made for each child. A report summarizing findings and recommendations for each child was distrib- uted to parents and, with parental permission, to school personnel and the child’s primary care provider.

Discussions with parents, teachers, administrators, and students have identified a number of the program’s strengths. Direct access to the child in a school setting allowed for more extensive data collection than would have been possible in a clinic setting. Information and impres- sions were gathered conveniently from school personnel, and school records were easily accessible. Observations of children in the school setting were a rich source of informa- tion that would not have been otherwise available about a child’s behavior and style of learning, teachers’ styles, and interactions with classmates. In some cases, initial neurode- velopmental testing did not provide sufficient information about a child to answer referral questions. Such factors as a mismatch between a test and a child’s abilities, testing interruptions (fire drills), an “off-day’’ for the child, or the child leaving his glasses at home interfered with data gath- ering. In these cases, a second testing session was sched- uled easily. The program’s location in the schools allowed the nurse practitioners to develop relationships over time with school personnel, families, and students. Daily contact with parents, teachers, and children encouraged communi- cation and trust that may not have been possible in a more conventional evaluation setting. The relationships which developed were a unique source of anecdotal and diagnos- tic information about children. Children became accus- tomed to seeing the nurse practitioners in their school and classrooms. Not only were they not intimidated by the nurse practitioners, they often asked, “When is it my turn to go with you?’ Assessments were seen by many children as a positive experience or reward. As a result, they appeared more relaxed during testing and likely provided a more accurate indication of their optimal level of functioning.

244 Journal of School Health September 1996, Vol. 66, No. 7

The nurse practitioners’ presence in the schools also improved access to medical consultation for school person- nel and families. For example, a number of parents and teachers requested information about the effects of medical conditions such as seizure disorders, elevated blood lead levels, and head trauma on school performance. Familiarity with the program and ease of access to the nurse practition- ers made it possible to assist families of children not other- wise identified by the schools. For example, the parents of a quiet child who was doing well academically initiated contact with the program’s nurse practitioner for concerns about their child’s emotional well-being. In addition, school nurses frequently sought consultation when children presented with medical complaints such as skin rashes, ear infections, or playground injuries.

The location of testing in the school saved families time and transportation costs. Children were away from class for less time than they would have been during a conventional office-based evaluation for school failure. Many parents reported no personal means of transportation, and appreci- ated the convenience of meeting at the schools.

In some cases, teachers and school personnel were unaware of important medical factors affecting a child’s performance. For these children, evaluation helped to more quickly identify significant issues which were not reflected in the original referral question. Examples of these include the child referred due to behavioral concerns who was found to have a history of traumatic brain injury, and the child referred for academic concerns who was found to have significant visual impairment.

In the first year of operation, a number of unanticipated problems were also identified. For example, the program’s independence from school governance and administration may not have been evident to all parents, due to the program’s physical presence in the schools and the pres- ence of the nurse practitioners at school PPT meetings. Parents who disagreed with the school’s views of their child may have been reluctant to participate in assessment by the program, believing that the program shared the views of school personnel. Acceptance of recommenda- tions made by the Ready-to-Learn program may have been influenced by this perception as well. Although parents were clearly informed that participation in the Ready-to- Learn program was voluntary and that refusal to participate did not limit a child’s access to other educational services, some seemed to feel that assessment by the program was a mandatory part of their child’s PPT process. Parents may have felt pressure from teachers eager to have a child assessed, or confused by the presence of the nurse practition- ers at PPT meetings. Such perceptions may have affected parents’ acceptance of assessments, as well as the accep- tance and implementation of program recommendations.

Recommendations for stimulant medication treatment for children with attentional problems proved to be particu- larly controversial. Parental acceptance of stimulant medication was limited to four of 15 students for whom it was recommended. Parents’ biases against stimulant medication seemed to play a role in their reluctance to initi- ate treatment, despite medical information provided by the nurse practitioners. Many teachers had strong opinions regarding medication and may have influenced parental opinion. Parents may have felt pressured by teachers to use medication, or may have been dissuaded from its use by

teacher opposition. Some school personnel seemed uncertain about the

nurse practitioners’ role at the school. This confusion contributed to an occasional lack of coordination of services. For example, counseling was recommended for some children assessed by the program who already were receiving such services from the school social worker. Confusion about roles and responsibilities of the program led to inappropriate referrals to the nurse practitioners to address mental health and social service needs.

Certain recommendations made by the Ready-to-Learn program were not implemented due to limited school and community resources. As previously noted, families usually waited months to get appointments to see a mental health therapist through the few agencies available in the area. This delay was even longer for Spanish-speaking families. Difficulties with implementation of certain recommenda- tions may have been perceived by school personnel and parents as an inherent shortcoming of the Ready-to-Learn program, rather than as a problem with community resources. For example, the program was not designed to address a number of significant needs of students and their families, such as psychological services, structured after- school activities, and mentoring programs.

CONCLUSION This school-based initiative was established to facilitate

prompt identification and intervention for inner-city chil- dren experiencing learning and behavior problems. In its first year of operation, the Ready-to-Learn program provided access to pediatric assessment for a group of 57 students at three elementary schools. Feedback from school personnel and parents suggests that this type of program offers a unique pediatric perspective to the evaluation of children with learning difficulties. Future efforts will focus on a more formal evaluation of the program’s effectiveness and acceptance. Specific questions to be answered include, but are not limited to, the cost-effectiveness of the program, whether pediatric assessment affects school success, and the extent to which communication is facilitated among school personnel, health providers, and families.

Based on the first year’s experience, a number of modi- fications to the Ready-to-Learn. program have been imple- mented. In response to the frequently cited need for mental health services for students and families, additional grant support was solicited and secured to add a group counsel- ing component for parents and students. Continued dissem- ination of information about the program’s goals and guide- lines is planned through outreach efforts to parents during Parent Teacher Organization meetings and open houses, as well as through memos and meetings with school person- nel.

No data are yet available regarding the Ready-to-Learn program’s cost effectiveness, including the cost of nurse practitioner hours per assessment. At the least, the program has the potential to be cost-effective, given the likely savings in reimbursement costs for nurse practitioner services as compared to the cost of referrals for comparable services typically offered by physicians and specialty clin- ics. Ideally, the Ready-to-Learn prototype may prove to be most cost-effective as one component of a comprehensive, school-based primary care clinic.

Journal of School Health September 1996, Vol. 66, No. 7 245

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